Monday, November 8, 2010 - Noon
Lars Svensson, MD, PhD
Director, Center for Aortic Surgery and Director, Aorta Center, specializing in the treatment of Marfan Syndrome and Connective Tissue Disorders
Cleveland Clinic Department of Thoracic and Cardiovascular Surgery
Thoracic Aortic Aneurysms are deadly occurrences of the bulging of weakened wall of the aorta, the body’s largest artery. A thoracic aortic aneurysm is a serious health risk because, depending on its location and size, it may rupture or tear, causing life-threatening internal bleeding. When detected in time, a thoracic aortic aneurysm can often be repaired with surgery or other less invasive techniques. Dr. Svensson, a Cleveland Clinic surgeon, provides answers to your questions concerning Thoracic Aortic Aneurysms and its symptoms, diagnosis and treatment options.
Cleveland_Clinic_Host: Welcome to our "Thoracic Aorta Surgery" online health chat with Lars Svensson, MD. He will be answering a variety of questions on the topic. We are very excited to have him here today!
Cleveland_Clinic_Host: Thank for joining us Dr. Svensson, let's begin with the questions.
Aortic Aneurysm Symptoms
jebasques: I would like to know if an aortic aneurysm or other Marfan-related problem could cause a balance disorder. Thank you.
Dr__Svensson: No - in general that would not be the case, however, if somebody was on low blood pressure medications or has severe narrowing of the aortic valve (stenosis) then they can have a balance disorder. Generally, balance disorders are related to the cerebellar part of the brain or middle ear problems.
Aortic Aneurysm – Diagnostic Testing
lmgaiso: What is the sensitivity of an echocardiagram detecting a thoracic aneurysm?
Dr__Svensson: Echo is not as accurate for screening aortic aneurysms as MRI or CT.
mcm01s: How often should an ascending aortic aneurysm measuring 4.2 be measured?
Dr__Svensson: Six months after the first study and then yearly depending on age.
mthirtle: Is an ultrasound as accurate as a CT scan for diagnosing the true measure of an aortic aneurysm—I've had both and the numbers are slightly different (4.3cm vs. 4.5cm)
Dr__Svensson: No - CT is more accurate.
Aortic Aneurysm – When to Operate
KathyM: my mom has 2 aortic aneurysms one in the stomach and one in the aorta. She had them checked last month and her doctor stated that they were at a four. she made her an appointment at the end of the month of Nov. this matter is serious and she cannot wait till the end of the month they are growing rapidly. They burst at five and surgery is only done at five or under. she has Medicare plus Kaiser Permanente, which I believe if Kaiser does the operation she will die and if she don’t have it done she will die. Is there accommodations for her and family members and how will we know if she qualifies. This has to be done now any longer and I'm afraid we will lose her. Your quick response will be greatly appreciated.
Dr__Svensson: There are many factors that go into deciding when to operate and what approach. It sounds like your mother's aneurysm is in her abdominal aorta below the kidneys. In that case, most patients are treated conservatively until they get to 5 to 5.5 cm. One option is insertion of a stent for the aneurysm. It would be worthwhile to have a repeat imaging study 6 months after the first one to see if it is growing.
JenniferC: Hello. My brother lives in Germany (job related) and is being followed for aortic aneurysm, also bicuspid valve. He had a MRT done this week and his aortic measurement was 5.3 ?? They want to do surgery very, very soon. He is 41 y.o. and is also a smoker. His EKG was not normal. He has noticed more palpitations within the past few months. I am his sister and have been researching where to have the procedure done (aortic resection?). Would he be safe to travel? Would he be able to get an appointment quite soon for evaluation and possibly surgical intervention? Per the research online - your facility seems the place to go for experience and outcome both very, very, very important to me. Thank you for your time! Regards, Jennifer Also, I believe his insurance is Blue Shield Federal Plan - hope you are a participating hospital
Dr__Svensson: At 5.3 cm your brother certainly needs the aorta to be replaced and depending if the bicuspid valve has a leak or narrowing it may require repair or replacement. Based on our experience with over 5,000 patients with bicuspid valves, we quote a 1% risk of death with surgery. We do over 950 thoracic aorta operations a year and dealing with patients with bicuspid valves and ascending aortic aneurysms is one of the more common operations we do.
It should be safe for him to travel as long as he is not having chest pain.
Please contact Rhonda and Becky in my office for a surgical review.
Dr. Svensson's office phone number is 216.445.4813 or toll free 800.223.2273, extension 54813.
hafiz: Aortic aneurysm is located at/near heart; 47mm. It was 42mm in 2007; it has not increased in size for 18 months. Is surgery an option or a necessity? If surgery....please provide details. Thanks
Dr__Svensson: At the size of 47 mm the risk of further growth is dependent on age, other connective tissue disorders like Marfans, and blood pressure. Generally, once the aorta gets bigger than 4.7 cm, growth does not stop.
Generally we don't recommend surgery at 4.7 cm unless the patient has Loeys Dietz syndrome.
gregs: My ascending aortic aneurysm is 5.1 cm and I have no symptoms and am in good health. The aneurysm has been stable for at least 14 months (since date of discovery). My Doctor indicates that I should wait until it reach 5.5 cm before surgery. Although I am certainly not anxious to be operated on, is it wise to wait and see?
Dr__Svensson: At 5.1 cm, a lot would depend on your age and whether you have any other problems like a bicuspid valve or Marfan Syndrome. If you have either then you should consider surgery.
jcl: If an aneurysm grows 4-5mm in a year, is surgery indicated?
Dr__Svensson: Generally yes.
Aortic Aneurysm – When to Operate (Marfan Syndrome)
rampanand: A 33 year old male with Marfan Syndrome had an aortic dissection beginning just below the takeoff of subclavian artery. The dissection flap extends distally and terminates at the take off mesenteric artery. The dissection flap did not extend into the celiac artery or superior mesenteric artery. The dissection flap is noted to be discontinuous at its point of termination. There is no evidence of acute aortic aneurysm. maximum ascending aortic diameter is 3.7 cm and descending 2.4 cm, suprarenal abdominal aorta is 2.2 cm, and infrarenal aorta is 1.9 cm.. This episode occurred on 2/6/2009. The patient was treated conservatively and discharged and is doing well. The question is any graft or other procedures be considered to prevent any future episodes. thanks, email@example.com
Dr__Svensson: Based on the information provided we would not recommend any surgery at this time. But careful follow up is required by MRI on a yearly basis to make sure it is not growing or exceeds about 5.0 cm.
jcl: At what size should a thoracic aortic aneurysm be operated on for someone who has Marfan and has had a descending dissection? Does a person usually experience chest pain with a thoracic aortic aneurysm?
Dr__Svensson: The timing of surgery in a patient with Marfans and dissection of the descending aorta is dependent on growth rate and height - usually when the aorta exceeds 5.0 cm, we follow patients more carefully and if the size exceeds 5.5 cm, we are more prone to operate.
Patients with chest pain in association with aneurysms we generally recommend that they undergo surgery.
Aortic Aneurysm – When to Operate (Turner’s Syndrome)
Connie: First , I would like to thank Dr Svensson for taking time out of his busy schedule to host this live chat. It is very important for me and I appreciate his efforts. I have a multiple part questions. Is it possible to view the aorta on a echo vs. an MRI. Would you briefly explain the numbers that some cardiologist give to the parents when discussing the size of the enlarged aorta vs. the ASI. For example my daughter has turner's syndrome diagnosed at birth, aortic enlargement discovered this year currently is 3.9 ASI 7.8. There is not as much research on Turners Syndrome and aortic disease say vs. Marfan does that factor in when you may decide when or when not to do surgery. My final question what do you do when the family is doing everything to prevent the worst case scenario and the child you have known starts changing and becoming distant, worried, 0r reckless because of the diagnosis. Thank you for you time
Dr__Svensson: Generally echo size is an internal measurement of the aorta and MRI or CT may be either internal or external measurement. This can lead to discrepancies in the size measurements.
It is true that for Turner's syndrome there is not much data on timing of surgery. Hence, when we drew up the guidelines for when to operate on patients with Turner's syndrome, we did not make any hard and fast rules. For most patients we find it useful to measure the cross sectional area of the ascending aorta and divide it by the patient's height in meters. If this ratio exceeds 10 we recommend surgery. However, every patient's findings need to carefully evaluate.
Aortic Aneurysm Surgery – Success Rates
RobertB: I had an aneurysm which grew to 5.5 cm before it was repaired. Added complications from the surgery (vfib for ten minutes with no pulse followed a few days later by liver and kidney failure) led to my spending 43 days in the hospital and several weeks in intensive care. I also had a congenital caved in chest —- and a bicuspid aortic valve.
Dr__Svensson: It sounds like you had an unfortunate outcome; based on what I can figure out we would normally quote a 1% mortality rate and a 5 - 7 day hospital stay.
bossprez1: Two years ago I had a 5.6cm ascending aortic aneurysm repaired with valve saving reimplantation. I'm 64 in otherwise great health. My recovery was very good with occasional transient AFib which has now gone away. I have no other issues other than mild RA which currently is not bothering me. What is the latest on life expectancy for people my age and who work out and stay very active
Dr__Svensson: I don't have specific life tables for your age but our data on David Reimplantation show a normal life expectancy after repair.
Aortic Aneurysm Surgery: Minimally Invasive Keyhole Approaches
Spencer: Any advances in robotic/minimally invasive repair of ascending aortic aneurysms? For two years my measurements via CT scan have ranged from 4.5 to 5.2. Average just under 5. No evidence of enlarging trend. No idea how long the aneurysm has been there. Could have been many years. I am 70. Have been advised to monitor this once a year. Any comments? Thank you, Spencer
Dr__Svensson: There have been some attempts at fixing the aorta with robots but generally the problem has been that the period of stopping the heart or clamping the aorta has been excessive and the complications have been severe.
We find that a keyhole minimally invasive operation achieves excellent results with good cosmesis, less blood loss, less pain, and quicker recovery from a breathing point of view. Indeed we tell patients they can start driving 2 weeks after surgery.
Andy: Is there minimally invasive surgery available for repair of (i) ascending aorta aneurysm (root currently dilated at 4.3 and ascending aorta at 4.8), with (ii) aortic valve moderate regurgitation? Or is the only option fully open chest surgery if/when the aorta dilates a little further? Is an endovascular stent graft an option?
Dr__Svensson: I routinely do 2 or 3 minimally invasive ascending aorta and aortic valve procedures every day. So for most patients we do this through a key hole incision of about 7 - 9 cm. This has turned out based on our studies to be an excellent way to manage these aneurysms.
If however, you need a David Reimplantation of the aortic valve, which would be specifically for keeping your tricuspid 3 leaflet valve and repairing the valve and your root, then in that particular situation I mostly open the chest. We have done over 280 David Reimplantations and I have not had a postoperative death, however, since this is a more complicated operation that is only routinely done at 3 institutions in the U.S., it is safer to use a full sternotomy.
Stent grafts are not an option for ascending aorta surgery.
wjalmon: I have been diagnosed with an ascending aortic aneurysm: 4.4 cm with echocardiogram; 4.7 cm with non contrast CT scan (calcium score zero), and contrast CT scan indicated 4.6 cm x 5 (not sure what the X5 indicates). I also recently learned during the echocardiogram that I have a bicuspid aorta. What are the recommended treatment/procedures for my condition. I am 54 years old, in good health, asymptomatic, but have had hypertension or prehypertension for several years. I have recently been prescribed lisinopril (10mg) daily and have been told by my cardiologist that my BP is in control. The cardiologist recommended seeking surgical advice based on the aneurysm. Are there any good articles/books to read? I will be seeking surgical advice and services in the not too distant future.
Dr__Svensson: Once again if your aneurysm cross sectional area to height ratio exceeds 10, then we would recommend surgery. As far as articles to read about the surgical technique, I wrote a reference text book on the cardiovascular surgery of the aorta but more accessible to you would be the thoracic aorta disease (TAD) guidelines from the American Heart Association that I was a co-author on.
If you go to www.pubmed.org and search TAD guidelines or Svensson LG, you will find useful literature.
wmurray8: What procedure is used for repair of a thoracic aneurysm?
Dr__Svensson: The procedure of repair of an ascending aortic or aortic arch aneurysm involves sewing in a new tube made out of dacron polyester plastic material. For descending or thoraco-abdominal aneurysms an endovascular stent graft may be an option
rh_atlanta: I have a 76-year-old family member in Belgium that needs repair of a thoracic aortic aneurysm. He wants it done endovascularly because he believes the mortality rate is lower and recovery time quicker. His aneurysm is 6,4 cm per one physician and >5,4 cm from another. Three questions: (1) should the aneurysm be measured from outside to outside, or inside to inside? (2) what is the general mortality rate for endovascular v. open, and (3) what is your patient mortality rate for the two procedures? As an aside, I have sent med records to you as a consult for this patient. Thanks.
Dr__Svensson: The size of the aorta should be measured by the external diameter axial to the blood flow stream. If this is not done then there will be differences in size measurements.
It is unclear the extent of the aneurysm and if aortic dissection is present. Generally for descending aortic aneurysms, without aortic dissection, we repair them with stents. In one of our studies, patients with aortic dissection had similar outcomes with either open or endovascular repair but less re-interventions with open repair. Every patient needs to be carefully evaluated for the best option.
AMHAPPY10: are there non surgical treatments for an aortic aneurysm
Dale: Are there new surgical techniques being developed which would be particularly helpful to treat aortic aneurysms for people with Marfan?
Dr__Svensson: See the above discussion about the David Reimplantation operation. This is mostly considered the standard of care. You can find information and a video on our website about the David Reimplantation.
cbelt1219: I am a 58 yr. old female who has a St. Jude mechanical aortic valve placed in April 2005. I had a bicuspid valve defect as does my 22 yr. old sin, my sister, and a first cousin. Immediately following my surgery, while in recovery, I had a blockage of my right coronary artery and subsequent cardiac arrest. A bypass was done and I have fully recovered except for mild atrial fibrillation. This spring, I saw my cardiologist for a routine ECHO and check up. He explained that recent research has found people with mechanical valves are having some "dilation" of the aortic arch 5 to 10 yrs. after surgery. My ECHO showed a dilation measurement of 4.1mm. I was subsequently sent for a CTa scan which showed a dilation of 4.7mm. The cardiologist said that when the dilation is 5.5mm it will be "time to do something" although I would be "hard pressed to find a surgeon willing to touch someone who had been on blood thinners for 5 to 10 years". I have since learned from my primary physician that the so called "dilation" is an aneurysm. The plan is to send me for another CTa scan after Christmas. What, if any, options do I have? How much risk is there for surgical intervention? Are there any Cardiovascular surgeons in the Buffalo NY area who are experienced enough to help me?
Dr__Svensson: Patients with bicuspid valves are prone to aneurysm formation if at the original operation the aorta is more than 4.5 cm.
Hence, we routinely repair the aorta if it is above 4.5 cm in association with aortic valve disease. With that policy, we have a 98% freedom from reoperation on the aorta 10 years after surgery in some 2000 patients we studied a few years ago. This is coming out in a publication shortly.
As far as timing of surgery in patients who subsequently develop aneurysms, that is somewhat related to the patient's age and general condition. Since you are 58 years old, I would recommend that when you get above 5 cm, you should be evaluated for potential surgery. If you have no significant comorbid disease I would quote you a 2 - 3% mortality rate based on our experience.
edg202: What is the probability of a second ascending aortic aneurysm developing several years after a first occurrence was successfully resected?
Dr__Svensson: That is very dependent on what the original indication for surgery was. As mentioned above, if you had a successful resection in association with a bicuspid valve, the risk is only 2 % in the next 10 years.
If the reason was aortic dissection, then the risk goes up to about 10%.
Gerald: I had open heart surgery in 1992 for an aortic aneurism that had caused my aortic valve to blow. My surgeon was Dr. Christopher Gibson at St. Bernadine Hospital in San Bernardino, Ca. I have a new aneurysm forming at the edge of the old patch. Composite surgery is required and Dr. Gibson says that the only Dr. he would want to perform this surgery is Dr. Lars Svensson. My cardiologist is trying to persuade me to have the surgery at The UCLA Medical Center. My question is twofold: How long a wait before I could schedule surgery with you? And Is the fact that post-op complications are common for this type surgery a possible reason to consider having the surgery closer to home i.e. UCLA? Thank you,
Dr__Svensson: Dr. Gibson is an excellent surgeon and I would value his advice to you. Repeat aneurysm formation can happen particularly after aortic dissection repairs. It sounds like you may have had acute aortic dissection and Dr. Gibson saved your life.
We would be happy to evaluate your situation and my schedule is usually 6 weeks before surgery. I would not particularly consider it a problem to travel for or after surgery.
moncleb: I had surgery for coarctation of the aorta when I was 18 and a 16mm dacron tube was put in. Now I am 54 and I had a CT angiogram that showed my aorta is 25mm right above and below the repair and16mm at the repair site. I also have an ascending aorta aneurysm of 4.5cm. I know an ultrasound showed the aorta was 3cm 2years ago. I still have chronic pain in my side and back from my thoracotomy 36years ago. I really do not want to add to it with another surgery. What part should I be concerned about? How long can I wait to have either fixed? Can I do any type of exercise?
Dr__Svensson: Based on what you have which includes a small 16 mm tube graft repair and an enlarging ascending aorta, and if you have average height I would recommend that when you get to about 4.9 cm you consider having an ascending aorta repair combined with a bypass of your coarctation. This sounds complicated but is a relatively straight forward operation for your problem.
hermes: Is the Gelweave Valsalva graft approved by FDA a preferred graft for ascending aortic aneurysm repair? Could you please go over the pros and cons for this graft?
Dr__Svensson: The Gelweave graft is approved by the FDA. Its advantage is that the gel is quickly absorbed and antibiotics bind to the gel.
wmurray8: With 3 prior AVRs and scar tissue how difficult does it make aneurysm repair?
Dr__Svensson: It is somewhat more difficult but there are ways of doing this reasonably safely as long as there were not major problems with the previous operations.
Aortic Aneurysm Medications
txjessy: 33, female, diagnosed with TAA ascending (4.3cm) and bicuspid Aortic valve. No hypertension. Asthma and allergy injections. Family history of congenital heart defects and aneurysms. How important is it to take Beta Blockers (Toprol)?
Dr__Svensson: The evidence for using beta blockers for aneurysms is mainly based on trials in patients with Marfans Syndrome. Intuitively, we do however believe that if patient’s blood pressure is kept lower in patients with aneurysms the risk of growth is slowed down. At your size, I would therefore recommend a beta blocker if you tolerate it.
Martin: What are the best medications to take to reduce risk for one who has a thoracic aneurysm? How long should it take to complete an operation for a thoracic aneurysm and two leaking valves? What is the recovery period? Will a non-invasive operation for a thoracic aneurysm ever be developed, and if you think it will happen, when? What is the mortality rate for a patient when a thoracic aneurysm and two leaking valves are operated on? How many doctors on staff perform the above operation? Are the mortality rates the same for all of the doctors on staff who perform the operation? How big does the aneurysm have to be for an operation to take place? How often should a cat scan be given to determine the size of the aneurysm? Is there a better indication other than a cat scan?
Dr__Svensson: Medications can slow down the growth of aneurysms depending on the initial size.
Mostly I stop the heart for about 25 - 45 minutes for replacing or repairing the aortic valve and replacing the ascending aorta.
The minimally invasive key hole operation is an excellent option as discussed above. Generally, the more a surgeon does an operation, the better the outcome.
AMHAPPY10: On your web site it mentions other treatments for an aneurysm. Mine is in the aortic root. I was told it would be monitored and a dacron valve could replace it. Is there other treatments? My is 3.7-3.8 cm
Dr__Svensson: At 3.8 cm we would recommend follow up and careful blood pressure control. If your cross sectional area divided by height gets to exceed 10 then we would recommend surgery.
Aortic Aneurysm – Exercise
Cornelia: I would like information in regard to types of exercise and limitations. I have been diagnosed and monitored since 5/08 with a 4.1cm ascending aortic aneurysm. I am 67 year old female with low blood pressure and normal blood work tests. I very much want to maintain well functioning physical body Any suggestions or guidelines, please.
Dr__Svensson: We generally recommend aerobic exercise at that size with no rapid upper chest movement while straining. Cycling, swimming, walking are all good options.
lmgaiso: Is there evidence that people who lift weights regularly are at greater risk for an aneurysm? If so what can be done to mitigate this risk?
Dr__Svensson: Weight lifting is a risk factor for aortic dissection and may accelerate aortic valve leakage.
wmurray8: Would you say that playing golf could be detrimental to someone with a 5.0 CM aortic aneurysm (ascending aorta)?
Dr__Svensson: While some people consider golf safe with aortic aneurysms at your size I would not recommend golf since I have seen patients develop aortic dissection
FMD and aorta
lindalwml: I am a patient with Fibromuscular Dysplasia (FMD) which affects the larger arteries and is related t a connective tissue disorder. Can FMD be a cause of aortic aneurism?
Dr__Svensson: Yes but it is unusual.
Aortic Valve Surgery
sadams: Can the body reject this valve?
Dr__Svensson: The native aortic valve in humans can be affected by autoimmune diseases like lupus, rheumatoid arthritis and takayasu arteritis. The replacement valves like cow valves (pericardial) and pig valves are treated with gluteraldehyde which makes them immunoprotected - and essentially turns them into "leather" so they do not get rejected.
wmurray8: Would you replace a 13 YO bio-prosthetic aortic valve at the same time as repair of an aortic aneurysm (thoracic)
Dr__Svensson: That would depend on what your valve looks like on echo and at the time of surgery and your age. Probably it would need replacement.
Cleveland_Clinic_Host: That is all the questions that will be answered today. All further questions have been answered in prior questions.
Dr__Svensson: Thank you for having me today, there were some great questions.
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